You’ve just started working the 7a – 7p shift in your ED and you get the rundown from the overnight physician and the charge nurse on duty. It’s a typical morning, but you expect the chaos to really begin around lunchtime as it always does. Sure enough, by 1pm, the ED is bustling and every time you turn around, there is another patient coming in from the waiting room.

Are you surprised to see that these patients who have been brought into the ED to be evaluated come with a nasty look of frustration and an attitude to match? When subjected to unnecessary delays that relate to ED front end intake processes, patients can be fuming and the worst part is, you may spend a significant portion of your shift “catching up” to the constant influx of patients.

In many cases this “lunchtime rush” actually traces back to delays related to the ED front end processes that started a couple of hours before and will impede patient flow for hours afterwards. Queuing theory helps to explain why this happens.

Minding Your Ps and Qs (Patients and Queues)

Queuing theory is the mathematical study of waiting lines, and looks at variables such as the arrival rate of customers and the rate at which they can be served. If the arrival rate is greater than the service rate, a queue (waiting line) will form. Let’s say a triage exam takes an average of 8 minutes to complete and there is a queue of 5 patients. The unlucky patient who is at the end of that queue will wait about 40 minutes just to get to triage (unless they balk the queue and leave without being seen). So, even if they received a full registration taking 10 minutes and then wait another 10 to be brought into the ED, it will be at least 1 hour of waiting before they see the physician!

ED Front End Improvement Practices

However, there are several practices which can be implemented to reduce or eliminate front end bottlenecks in your ED that will minimize arrival to bed placement time, satisfy your patients and create a manageable stream of patients into the ED. Some require an investment in staffing or equipment and others require no investment at all as they simply represent process redesign. The following are some of these practices and pros and cons of each:

Computerized Kiosk Sign In

Upon arrival, patients enter their name, date of birth, age and the reason they have come to the ED in a computer terminal kiosk. This information interfaces with the electronic tracking system so the triage nurse knows the number of patients in the waiting room that have to be triaged and some background information.

Pros: Helps the triage nurse manage the number of waiting patients and those in the ED to be aware of what the waiting room looks like.

Cons: Language barriers, computer illiteracy and physical/emotional state of patients may prevent them from accurately completing the form or using it at all.


Demographic information is collected from individuals in the community in advance from to create medical records for a potential ED visit in the future. If/when they arrive to the ED, most of the registration is already completed.

Pros: Eliminates much of the time spent registering patients prior to going to an ED bed. Excellent marketing tactic to increase ED volume.

Cons: Requires substantial investment in set up/management costs as well as planning and coordination with hospital marketing department.

Quick Registration

Minimum amount of information needed from patients (name, date of birth, sex, social security number, reason for ED visit) to create a hospital account is collected during registration. Bedside registration occurs later in the ED visit to collect the remaining information (i.e. insurance).

Pros: Reduces registration cycle times and allows labs and diagnostics to be ordered directly after, due to creation of medical record number.

Cons: Requires consistent training across registration staff and possible modification of registration system to support this function.


Dedicated registrar staff located at walk in entrance who conducts a quick registration (see above) upon arrival.

Pros: Allows standing triage protocols to be executed, due to creation of medical record number. Greeter can provide other information and assistance to arriving patients which can improve patient satisfaction.

Cons: Requires additional investment for staffing and computer and possibly for recongifuration of waiting room.

Physician/PA in Triage

Physician or PA placed in triage to quickly begin evaluation/treatment of patients.

Pros: Large patient satisfier with quick provider contact. Rapid treatment and disposition of low acuity patients

Cons: Unproven model which can compromise and complicate the triage process and create friction with nursing staff. Additional provider staffing costs.

The “Waitless” ED

Waiting room chairs are for family members as the patient has a quick registration upon arrival and is brought directly to a bed afterwards.

Pros: Expedited arrival to bed time and tremendous patient satisfaction initiative.

Cons: Requires significant planning, process redesign and financial investment to ensure effective processes and appropriate ED bed and staffing capacity exist.

From Here to Where?

Unsure of which strategies are best for your emergency department? Here are some starting points:
Determine the waiting room bottlenecks. Assess your front end operation to determine in which queue patients are waiting the longest: triage, registration or bringing patients to a bed. Find out during what time of day each of these queues begin to develop and when they attain maximum values.

How big is too big? In order to streamline the front end process and minimize arrival to bed time, those staff performing the triage, registration and charge function need to be aware of their respective patient queues and when they exceed their ability to manage them. Once these queues reach this threshold, processes should be in place to identify additional help (i.e. double triage rooms, pulling a registrar from another area) in order to decrease the queue length.

So the next time you find yourself caught up in the midday crunch in the ED, imagine what it would be like to experience patient flow with manageable constant arrivals as opposed to inconsistent boluses of patient caravanning from the waiting room. Adoption of one or more of the aforementioned practices may help achieve this and transform your waiting room into simply an “arrival room”.
Eric Bachenheimer is the Director of ED Solutions, which provides consulting services to emergency departments and physician practices through its parent company, Emergency Medical Associates (EMA).


# For More InformationEric Bachenheimer 2008-02-05 15:11
For more information on some of these strategies, feel free to contact me at info@emaedsolutions.com or visit our website at www.emaedsolutions.com.

Eric Bachenheimer
# Correct WebsiteEric Bachenheimer 2008-02-05 15:13
Sorry - the correct website is:

# Creating a customer friendly modelDan Handel 2008-02-06 22:02
We have a lot to learn from the customer service industry. Triage should exist only when the amount of patients exceeds the number of beds available. Otherwise, all patients should be brought immediately back after obtaining a chief complaint and perhaps one set of vital signs (the latter is optional since if they can walk, their vital signs are not likely too bad). Disney has perfected the art of waiting by setting the expectation for waiting lines then exceeding them. Even when people have to wait, the reason they elope is that they are not sure when they will be seen. If you tell them it is going to be 90 minutes and they are seen in 80, they are pleased. If you tell them you can't guess, then they will go elsewhere.
# Chair, Norwalk Hospital EDMichael Carius 2008-02-07 14:28
Since "triage" is largely a nursing function, we need to work with our nurse colleagues to emphasize that "triage" is by definition a short process, a simple sorting out of who requires emergent vs. urgent evaluation and care. Unfortunately, most of us are stuck with traditional "triage," which is far more complex and really is "initial evaluation," which is very time-consuming.
# TriageERMurse 2008-02-28 18:13
ENA standards for Triage are 2-5 minutes. If its taking consistently longer than that then there is something wrong with the process, the documentation tool, physical layout, staff competency or communications skills, or what is being expected of the Triage Nurse to collect. For example, Medication reconcilliation cannot be done at Triage if the patient takes more than a couple of meds. Seeing the patients list is important for some presentations to accuratly assign an acuity but the rest needs to be done at the bedside. Its hard to see how shaving a few minutes off the process by eliminating Triage will benifit flow. The alternative of no triage creates chaos. You end up with high acuity patients in fast track, low acuity patients filling up your main ED and essentially a first come first served system. The ED I have worked at has had several sentinal type events related to high acuity patients with subtle presentations being treated and released from fast track by PA's. The elimination of an effective Triage system for the sake of expediency was the root cause in both cases. The real gains in patient flow have come from immediate bedding after triage when a bed is available and bedside registration.
# RN, BSN, CEN, CPENWilliam Maley 2014-09-16 00:47
Interesting points. Do you have a reference for "ENA standards for Triage are 2-5 minutes"? Have you seen anything about how long it should take from door to get Triaged? We are struggling with the problem of Triage versus initial evaluation like others.
# ED RNdana 2008-11-16 18:13
We have recently gone paperless in our ED. There has been recent talk regarding bedside triaging and MD's seeing patients within 8 min of patient arrival. I am looking for some studies done on patient satisfaction or personal experience. As an RN I am beginning to pitty the Dr. that need to rush and see a patient for satisfaction purposes. I feel that this new trend is setting up MD's to make unwarrented errors. I, like most of my colleagues are amazed that Medicare is dictating medicine in our hospitals and elsewhere. Patient satisfaction will decide whether or not the hospital gets paid, I wish restaurants were like that!!!

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